- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.60 / $609.03 / $3,955.04
| Facility | | $330.60 | $609.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.03 / $92.19 / $130.82
| Professional | | $45.03 | $92.19 | $130.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.08 / $103.48 / $165.47
| Professional | | $50.08 | $103.48 | $165.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.73 / $129.40 / $236.54
| Professional | | $69.73 | $129.40 | $236.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.50 / $163.96 / $246.19
| Professional | | $104.50 | $163.96 | $246.19 |